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The ABCs of Setting up an ACOBecker's Hospital Review 5th Annual Meeting

Thomas A. Raskauskas, MD, MMMPresident/CEO

St. Vincent’s Health Partners2754 Main Street

Bridgeport, CT 06606Thomas.raskauskas@stvincentshealthpartners.org

www.stvincentshealthpartners.org(203) 275-0202

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Physician-Hospital Organization

Incorporated May 18, 2012

Started as a PHO with Physician and Hospital members

3 current risk based contracts including commercial and MSSP

First organization in the nation to achieve URAC Full Accreditation for Clinical Integration March 1, 2014

Currently 373 providers (278 physicians, 95 mid-levels), 1 hospital, 3 SNFs

Engaging HHC, Pharmacy, DME

St. Vincent’s Health Partners Overview

3 SOURCE: Adapted from Harold Miller: How to Create Accountable Care Organizations 2009

Opportunities for Healthcare Cost Reduction

Improved Inpatient Care Efficiency

Use of Lower Cost Treatments

Reduction of Adverse Events

Reduction in Preventable Admissions

Hospitals and Specialists

Primary Care Practices

Improved Prevention and Early Diagnosis

Improved Practice Efficiency

Reduction in unnecessary testing ER visits, admissions

and referrals

All Providers

Improved Management of

Complex Patients

Use of Lower Cost Settings and Providers

Lower Total Health Care

Costs

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Appropriate utilization of services in the appropriate setting

Population management

Quality based care

Alignment of Physician and facility incentives

Care coordination at the PHO level

Medical Management at the PHO level

Cost Containment

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What is a Physician Hospital Organization (PHO)?

A PHO is a legal entity generally formed by physicians and one or more hospitals with the intention of negotiating contracts with payers and sharing in the financial rewards of controlling costs while delivering high-quality care.

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An active and ongoing program to evaluate and modify practice patterns by the network’s physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality.

This may include:(1) Establishing mechanisms to monitor and control utilization of health care

services that are designed to control costs and assure quality of care

(2) Selectively choosing network physicians who are likely to further these efficiency objectives

(3) The significant investment of capital, both monetary and human, in the necessary infrastructure and capability to realize the claimed efficiencies

Clinical Integration

SOURCE: FTC/DOJ - Statements of Antitrust Enforcement Policy - 1996

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Governance

Corporate structure and bylaws

Strategic Planning

Legal Compliance

Professional relations

Physician Relations

Payer Relations

Clinical Quality, Utilization & Outcomes

Budget and Finance

Administrative Operations

IT

Elements of the Network Operation

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Corporate structure and bylaws

Decision of first contract

CMS MSSP-ACO

Commercial-CIN

Corporate Structure

IPA, PHO (joint venture), Super PHO

Subsidiary of hospital/health system

LLC, Inc.

Strategic planning

Legal compliance

Governance

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Establishes and maintains network relationships-assumes similar roles of insurers

Physician recruitment and contracting

Hospital recruitment and contracting

Ancillary facilities recruitment and contracting

Communications

Website

Branding/collateral

Newsletter

Informational/CME meetings

Professional Relations

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Care coordination/care management

Reports

Tracking and trending metrics

Provider and group specific reports/dashboards

Quality

Utilization

Cost/cost savings

Executive reports

Clinical Quality, Utilization & Outcomes

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Establishes and implements clinical quality improvement

Clinical Guidelines/Protocols

Network metric assignment

Remediation

Data review

Claims analysis

Risk assignment

Clinical care gap analysis

Clinical Quality, Utilization & Outcomes

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Hiring personnel

Creating infrastructure of PHO

Prior to contract start

Training

equipment

Physical space

Network Committee support

Administrative Operations

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Operational budget and accounting

Non-risk based contracting

Routine functions of budget and finance:

Capital to fund the organization

Membership fees

Contract fees

Grants/loans

Distribution of quality bonuses and shared savings

Develop methodology within restrictions of FTC for distribution based upon quality and utilization

Attribution oversight

Budget and Finance

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Risk based contracting

Reinsurance, stop-loss

Adequate financial reserves Operational budget and accounting

Payer contract oversight

Budget and Finance

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Network operational infrastructure-day to day operations

Network provider infrastructure

Inter-provider connectivity portal

Provider IT support

Installation

Help desk

IT contract oversight-rfps, compliance

Regulatory oversight

HIPAA

MU, PQRS

Information Technology

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Building a CIN: Work Plan

*CPRS = Clinical Performance Reporting System

BDC Advisors Clinical Integration: The Road to Accountable Care 2011

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Clinical Integration TimelineStart Finish 2012 2013

June July Aug Sept Oct Nov Dec Jan Feb March April May June July Aug Sept Oct Nov Dec

Budget Development 6/4/2012 12/31/2012

Identify initial network providers 6/4/2012 12/31/2012

Estimate patient population 6/4/2012 8/31/2012

Identify IT capital needs 9/1/2012 10/31/2012

Develop dashboard reports 9/1/2012 12/31/2012

Develop initial disbursement plan 6/4/2012 8/31/2012

Contract with payers 6/4/2012 12/31/2012

2012 2013

June July Aug Sept Oct Nov Dec Jan Feb March April May June July Aug Sept Oct Nov Dec

Operations Development 6/4/2012 12/31/2013

Readiness assessment/Gap analysis 6/4/2012 8/31/2012

Structure/Governance 6/4/2012 12/31/2012

Training 9/1/2012 12/31/2012

Accreditation 1/1/2013 12/31/2013

Credentialing 9/1/2012 12/31/2012

2012 2013

June July Aug Sept Oct Nov Dec Jan Feb March April May June July Aug Sept Oct Nov Dec

Quality and Utilization Review Development 6/4/2012 12/31/2013

Establish quality metrics 7/1/2012 12/31/2012

Develop dashboard quality reporting 7/1/2012 12/31/2012

Develop provider quality compliance program 7/1/2012 12/31/2012

Develop patient satisfaction survey 7/1/2012 12/31/2012

Develop patient satisfaction dashboard 7/1/2012 12/31/2012

Develop utilization metrics 7/1/2012 12/31/2012

Develop dashboard utilization reporting 7/1/2012 12/31/2012

Survey PCPs for PCMH readiness 6/4/2012 12/31/2012

PCMH accreditation for PCPs 9/1/2012 12/31/2013

2012 2013

June July Aug Sept Oct Nov Dec Jan Feb March April May June July Aug Sept Oct Nov Dec

IT Development 6/4/2012 12/31/2013

Provider EHR survey 6/4/2012 8/31/2012

Provider meaningful use survey 6/4/2012 8/31/2012

Provider E-prescribe survey 6/4/2012 8/31/2012

Initial IT capital requests 9/1/2012 10/31/2012

Develop initial IT rollout map 9/1/2012 12/31/2012

Implement IT rollout 9/1/2012 12/31/2013

Report programming development 7/1/2012 12/31/2012

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Questions?

Thomas.raskauskas@stvincentshealthpartners.orgwww.stvincentshealthpartners.org(203) 275-0202